"Medical Weight Loss Progress Note Template"

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Medical Weight Loss Progress Note
Name: _____________________
Date:_________________
Weight:_____________________
Blood pressure:_________
Change In Weight Since Last Visit:________ BMI:_________________
Diagnosis: ________________________________________________________________________________
__________________________________________________________________________________________
Diet Plan:
Include Notes From Diet Plan with PCP notes
Weight Watchers
L A Weight Loss
Jenny Craig
Eat Right
Other: (specify)____________________
Compliant with Diet Plan?
YES / NO
Weight loss medications: ________________________________________
Total Daily Caloric Intake:_______________
Physical Activity/ Exercise Plan:
Gym _____ x’s wk
Walking/Running _____ x’s wk
Aerobics _____ x’s wk
Exercise Videos _____ x’s wk
Inability To Perform- Comments: ___________________________________
Recommended Modifications: ____________________________________
Behavior Modification:
Dietitian Consult
Date:__________
Group Counseling
Date:__________
Individual Counseling Date:__________
Recommended Modifications:___________________________________________
Comments: (progress or lack of progress)
Provider Signature: ____________________________ Date:___________
Typed or Printed Name: ________________________________________
Medical Weight Loss Progress Note
Name: _____________________
Date:_________________
Weight:_____________________
Blood pressure:_________
Change In Weight Since Last Visit:________ BMI:_________________
Diagnosis: ________________________________________________________________________________
__________________________________________________________________________________________
Diet Plan:
Include Notes From Diet Plan with PCP notes
Weight Watchers
L A Weight Loss
Jenny Craig
Eat Right
Other: (specify)____________________
Compliant with Diet Plan?
YES / NO
Weight loss medications: ________________________________________
Total Daily Caloric Intake:_______________
Physical Activity/ Exercise Plan:
Gym _____ x’s wk
Walking/Running _____ x’s wk
Aerobics _____ x’s wk
Exercise Videos _____ x’s wk
Inability To Perform- Comments: ___________________________________
Recommended Modifications: ____________________________________
Behavior Modification:
Dietitian Consult
Date:__________
Group Counseling
Date:__________
Individual Counseling Date:__________
Recommended Modifications:___________________________________________
Comments: (progress or lack of progress)
Provider Signature: ____________________________ Date:___________
Typed or Printed Name: ________________________________________